Change Request Detail
No.
1202
Date
8/17/2017
Submitter
Type of Request
Retail Pharmacy Claim
Status
Business Analysis Complete - Recommendation Posted
Business Reason
The NCPDP membership is requesting the Subrogation Implementation Guide for Batch Standard version 10 be named in HIPAA to replace the  the Medicaid Subrogation Standard Implementation Guide, version 3. for Medicaid use only.

The Medicaid Subrogation Implementation Guide was established to address the Federal and State requirements for Medicaid Agencies to seek reimbursement from the correct responsible health plan. However, the Medicaid Subrogation Implementation Guide did not address similar requirements for other payers, such as Medicare Part D, State Assistance Programs or Private Health Plans. A standardized Subrogation Implementation Guide is needed to:
    Support compliance with requirements for recovery of federal, state and other plan overpayments
    Reduce manual processes currently required by pharmacies, PBMs and plans
    Provide a uniform approach to efficiently process post-payment subrogation claims and eliminate the numerous custom formats used in the industry today
    Achieve payment accuracy and support cost containment efforts

The Medicaid Subrogation Implementation Guide was used as the base to create the Subrogation Implementation Guide.

More information on this business function and background is found in the NCPDP Subrogation Implementation Guide.

Request the DSMO approve this change request and thus begin the process for the standard to be named in HIPAA for use by Medicaid Agencies.
Suggestion
Request the DSMO approve this change request and thus begin the process for the standard to be named in HIPAA for use by Medicaid Agencies.
DSMO Category
I
Recommendation
Approve. The DSMO is supportive of the work done by NCPDP to update this adopted standard and begin the process for a new version to be named in HIPAA.
Appeal Recommendation